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r WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERST CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 3151LNILE RD D.'f CITY/ZIPMANTECA 95337 CROSSSTREET AIRPORT WAY APN?14/-3 � PARCELSIZE ` LAND USE APPLICATION# OWNER NAME PETE BOYCE PHONE 479.2899 A� OWNER ADDRESS PO 9" 41 0 CITY/STATE/ZIP 1% CONTRACTOR N & S IRRIGATION, INC PHONE 209.599.3456 CONTRACTOR ADDRESS 215 W. MAIN STREET CITY/STATE/ZIP RIPON CA 95366 SUBCONTRACTOR SUBCONTRACTOR ADDRESS CITY/STATE21P PHONE LICENSE L, C-57 D C-61 7 D-09 )(Other C10 NUMBER 662732 EXPIRATION DATE 01/31/19 GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE X Domestic/Private I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization Public Water System If different from Owner: Water system Name ContaCt Name or 11hone Number TYPE OF WORK - New Well - Replacement Well ❑ Well Alteration/Modification D Other _ Monitoring Well(s) # of wells a Soil Boring(s) # of borings a Geotechnical # of borings - Out -Of -Service Well ❑ Out -Of -Service Well Renewal D Cross -Connection Repair - New Pump A Pump Replacement n Pump Repair R Raise Well Casing WELL CONSTRUCTION Drilling Method - Mud Rotary - Air Rotary - Auger n Cable Tool n Push Point r Other Proposed Well Depth It Excavation in diameter 3 Open Bottom I Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 7 Steel ❑ Plastic D Stainless Steel ❑ Other Grout Seal Depth ft u Neat Cement (94 lb bag15-10 gal water) a Sand Cement sack mixA gal water Bentonite (20% solids) D Other Grout Placement Method n Pumped ❑ Free Fall ❑ Other I Retardant / Accelerator (name) PEDESTAL Installed By i Driller a Pump Contractor Other Concrete Pedestal _. Dimensions: Width ft Length It Thick in - Christy Box -1 Stove Pipe PUMP XSubmersibleC Turbine ❑ Other HP -5 _ PumpSet_--82_ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS C E ND A VE WITH T E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL W KERS OMP TIOL U HU CE NOTICE REQUIRED FOR INSPECTIONS �-/JPLEASE CALL (209) 9 3-7697 SIGNED �� TITLE r' V lam+ ' r `� r L_� DATE I / _m M a O m H N OF ,,,-1VED HEALTH RENT Co Eyy QU/N N�1rH�FP 64'r�'hy aR �FNT Er RTMENT S/�Y Application Accepted By AA A Date Area Employee ID Ww Grout Inspection By Date ❑ PECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received f Soil Boring Inspecti �8G ' Cons ructeI�IJD�ept d7 �ft I'^ COMMENTSZt PE SC Received Chec Amount Codes Info B s Remitted Date PormlU Invoice # Well ID# Service Request # fmloqo4w 9I -003 051 VJV00393qE EH0 43-06 WELL /PUMP PERMIT 4/30/12 ill